Compression of Morbidity 2006

James F. Fries, MD

Brussels

March 22, 2006

0308061

Vision and Opportunity

• The health of seniors is our greatest national health problem

• The health of seniors is our greatest economic problem

• We know how to postpone ill-health and infirmity by ten or more years

• We know how to moderate medical costs by reducing the illness burden

0308062

Reduction in Need and Demandfor Medical Care

• Healthy People Need Less Medical Care

• The Health and Economic Solutions are on the Demand Side

• The Period of Maximum Employee Vigor may be Extended by Health Enhancement Programs

0308063

Reduction of Need and Demand Questions Sometimes Asked

• Will healthier people cost more by living longer?

• What is the length of the lag period between health risk reduction and positive health and cost benefits?

• Will we just make people healthier for their next employer?

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0308065

The Compression of Morbidity: Central Thesis

The age at first appearance of aging and chronic disease

symptoms can increase more rapidly than life expectancy

0308066

Scenarios for Future Morbidity and Longevity

Morbidity Death

Present Morbidity

I. Life Extension

II. Shift to the Right

III. Compression of Morbidity

56

7765

8060

8056

76

0308067

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Chartbook on Trends in the Health of Americans / Health, United States 2005

Life expectancy at birth and at 65 years of age by sex: United States, 1901-2002

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System.

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1901 1910 1920 1930 1940 1950 1960 1970 1980 1990 2002

90

80

70

60

50

40

Life expectancy at birth

Life expectancy at 65 years

Male

Male

Female

Female

Lif

e e

xp

ecta

ncy

in

ye

ars

03080610

Groups Threatened by the Paradigm of Compression of Morbidity

• Bioscientists Fearing Displacement of Funding

• Humanists Opposed to “Blaming the Victim”

• Geriatricians Worried about Lack of Preparation

• Pessimists Believing Goal Unachievable

• Demographers Vested in Contrary Predictions

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Evidence for Compression of Morbidity

• Multiple longitudinal studies documenting

morbidity compression by social class, exercise

level, education level, risk factors for heart

disease

• Multiple national surveys of disability since 1982

• Multiple randomized trials showing disability and

cost reductions with risk factor reduction

03080612

POSTPONEMENT OF DISABILITY

The University of Pennsylvania Alumni Statistics

• 1741 subjects studied over 50 years to age 77

• Three groups - low, medium, high risk based on smoking, body weight, and lack of exercise health risks at ages 40 and 62.

• The low risk group had only one-half the cumulative lifetime disability of the high-risk group.

Vita et al, NEJM, 199003080613

Cumulative Disability, Mean ValuesBars Represent S.E. of the Mean

0

0.5

1

1.5

2

All Subjects No InitialDisability

Alive andFollowed

Deceased

Low Risk Moderate Risk High Risk

Dis

abili

ty In

dex

Vita et al, NEJM, 199803080614

Disability Index by Year and Risk Factor Category

0

0.05

0.1

0.15

0.2

0.25

1986/87 1988 1989 1990 1991 1992 1993 1994

MinimumDisabilityHigh Risk

ModerateRiskLow Risk

Dis

abili

ty In

dex

Vita et al, NEJM, 199803080615

Disability Index by Age and Risk Factor Category

0

0.05

0.1

0.15

0.2

0.25

0.3

63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78

MinimumDisabilityHigh Risk

Moderate Risk

Low Risk

Age

Dis

ab

ilit

y I

nd

ex

Vita et al, NEJM, 199803080616

Running and Osteoarthritis (OA): A 13-Year Study

Wang et al, Archives Internal Medicine, November 2002

538 Runners 423 Controls

Average Age 58 in 1984

Followed Annually for:

• Disability • Pain • Osteoporosis

• X-ray Progression of OA

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Disability by Age and Runner Status

Age Category

Community Control (n=249)

Runners Club (n=369)

Mean

Dis

ab

ilit

y

Score

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-90

Wang et al, 200203080618

0.3 —

0.275 —

0.25 —

0.225 —

0.2 —

0.175 —

0.15 —

0.125 —

0.1 —

0.075 —

0.05 —

0.025 —

0 --- 59 60 61 62 63 64 65 66 67 68 69 70 71 72

Disability

Average Age, years

12.8y (95% CI, 8.3 to 20.6y)

8.7y (CI, 5.5 to 13.3y)

4.6y (CI, 2.5 to 7.3y)

| | | | | | | | | | | | | |

Runners (n=370)Community Controls (n=249)Postponement of disability (years)

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National Long-Term Care SurveysOver-65 Disability Distributions (%)

Manton and Gu, 2001

1982 1984 1989 1994 1999

Disabled 26.2 25.3 24.4 22.5 19.7

Mild Disab (IADL) 5.7 6.2 4.8 4.4 3.2

Moderate Disab (1-2) 6.9 7.0 6.7 6.1 6.0

Severe Disab (3-4) 3.0 3.1 3.7 3.4 3.5

Very Severe (5-6) 3.7 3.4 3.0 3.0 2.9

Institutionalized 6.8 6.6 6.1 5.7 4.2

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Recent Trends in Disability Among Older Americans

0

5

10

15

20

25

30

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

Year

NLTCS Any Disability

NLTCS ADL only

NLTCS IADL only

NHIS Any Disability

NHIS IADL only

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Self-Assessed Health Status as Excellent or Good: United States, 1991-2001

1991 1995 2000 2001

Total, % 89.6 89.4 91.0 90.8

Age, y

<18 97.4 97.4 98.3 98.2

18-44 93.9 93.4 94.9 94.6

45-54 86.6 86.6 88.1 88.3

55-64 79.3 78.6 82.1 80.8

> 65 71.0 71.7 73.0 73.4

> 75 66.4 67.8 67.8 69.2Source: Breslow, AJPH, 2006;96:17-19

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increased unchanged decreased

increasedAIDS

smoking

migraine

headaches

heart

transplant

decreased suicidecure

osteoarthritis

exercise

weight loss

Mortality

Morbidity

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A General Theory of Morbidity and Mortality

• Perturbations to the individual health may be classified quantitatively as increasing or decreasing morbidity and as increasing or decreasing mortality

• The individual is subject to many perturbations and it is usual for some to have positive and some negative effects

• Population morbidity and population mortality are the integrated sums of the positive or negative effects of perturbations on individuals

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Need and Demand ReductionRandomized Trials in Seniors

n time

health risk

score cost per person

savings per

person ROI

Bank of America 4,712

12 months -12% $29 $179 6.1

CALPers 57,268 12

months -10% $59 $300 5.1

Arthritis 809 6

months -7% $50 $260 5.2

Parkinson’s 290 6

months -10% $100 $570 5.7

Take Care of Yourself 2,833

12 months -17% $6 $20 3.5

Fries et al, Health Affairs, 1998

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The Key Targets for First Year Health Improvement and Cost Reduction

• Perceived Self-Efficacy

• Self-Management Skills

• High-Risk Persons

• Chronic Disease Patients

• Last Year of Life

• Low Birthweight Babies

• Absenteeism

• Productivity

• Corporate Image

• Employee Turnover

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ConclusionsTheory, Longitudinal Studies and Surveys

and Scientific Trials document that:

• Illness, infirmity, and frailty in populations may be postponed

by at least 8 to 12 years

• Disability is decreasing by 2% or more per year in many

developed countries. Mortality is decreasing at only 1% a

year, documenting Compression of Morbidity

• Health enhancement programs can improve health and

reduce costs in worksites, health plans, and in mature adult

populations

• Continued Compression of Morbidity is feasible

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